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Ultrasound Findings: Image 1: Suprapubic, longitudinal orientation demonstrating a viable ~8 week intrauterine pregnancy as well as a large amount of free fluid in the abdomen. Free fluid in this image seen surrounding the uterus superiorly and extending posteriorly into pouch of Douglas.
Image 2: RLQ view, longitudinal orientation. This image was taken just to the right of image #1. Again, large amount of free fluid demonstrated, this image (poorly captured by photographer Draper) demonstrated pronounced layering of the fluid, a characteristic appearance of blood leading to the increasing concern for hemoperitoneum.
Image 4: LUQ, splenorenal recess. Free fluid seen surrounding the inferior tip of the spleen. A pan positive FAST exam.
Discussion: Overall, 24yo G3P2 HIV positive female with history of 1 prior c-section presenting with 1 day of suprapubic abdominal pain, progressing to an acute abdomen with distinct rebound and severe tenderness throughout her abdomen. Initial evaluation was highly concerning for ectopic pregnancy in the setting of positive urine BHCG v appendicitis given fevers and tachycardia. However, abdominal US revealed a viable 8 week intrauterine pregnancy as well as a large amount of intraabdominal free fluid, highly concerning for blood. Pt was also noted to be febrile with MRDT positive for malaria. Thankfully, all the key players in the hospital were called to bedside after our initial exam was so concerning for an acute abdomen and marked intra abdominal fluid.
This is where the power of the bedside sono really became a key player. Neno has a functional operating theater, however, no one seemed too terribly thrilled to expeditiously take this stoic young woman to the OR on a simple clinical diagnosis of acute abdomen. Luckily for her, when multiple Clinical Officers and MD’s were able to see the images of the free fluid, the message became all the more obvious and no one could argue against an expeditious ex-lap.
After many hands confirmed the acute abdomen and many eyes saw the free fluid, she was rather expeditiously taken to the Operating Theater. We quickly researched possible causes of hemoperitoneum in the setting of pregnancy so we could be prepared to help in the hunt for the source of bleeding. So what is the differential for hemoperitoneum in pregnancy? Get ready for a list of zebras!
DDx for Hemoperitoneum in Pregnancy:
Placenta Accreta/Increta/Percreta: A range of pathologies in which there is abnormal invasion of the placenta into the myometrium. This is most commonly found in women with a history of cesarean, as the scar site is commonly the site of abnormal invasion. These related pathologies have different terminology to define the extent of invasion of the placenta into the uterine wall. Placenta accreta is defined as superficial invasion, placenta increta as middle layer invasion and placenta percreta as deep invasion. Placenta percreta is the most severe manifestation with an incidence of ~1:5,000-7,000 pregnancies. (Overall incidence of all forms of placenta accreta has increased significantly from ~1: 30,000 in 1950-60’s to 1:2500 in 2000’s. This is thought to be due to the parallel increase in the number of cesarean deliveries.) All of these pathologies carry a high morbidity given increased risk of hemorrhage, mostly noted during and immediately following delivery. However, I was able to find multiple case reports of placenta percreta in first trimester, most often diagnosed along with complete uterine rupture. Other risks associated with all forms of abnormal placentation include DIC, fetal demise and maternal death. Treatment worldwide is the same, hysterectomy. In the US, there are case reports trialing conservative management when possible (D&C, chemotherapy, attempted IR ablation) though none was found to be superior to hysterectomy, in fact, mortality rates were high in non-hysterectomy treatment.
Endometriosis/Endometrioma: Endometriomas are collections of endometrial tissue found outside the uterus, most commonly in the ovary. These are most often found on ultrasound in the setting of abnormal pelvic pain and bleeding. They can result in hemoperitoneum in the setting of rupture. Interestingly, however, when followed over the course of pregnancy, most endometriomas are found to shrink in size and many even regress in the setting of hormonal changes of pregnancy. pregnancy due to hormonal changes. Overall prevalence in pregnancy is 0.2-0.3%. However, despite their relatively rarity they account for approximately a quarter of all surgical interventions for ovarian cysts detected during pregnancy. Laparoscopy is the standard of care for surgical removal, though many studies report success in serial monitoring if endometriomas are incidental findings on routine ultrasound surveillance. Interestingly, when Jay and I asked about endometriosis in Malawi, none of the providers we spoke with could think of a patient they had diagnosed/or even seen with endometriosis.
Uterine/Ovarian Vessel Rupture: Again, another rarely occurring pathology. In fact, per one article, only 17 cases of utero-ovarian vessel rupture in pregnancy were noted on Medline search from 1987-2013. That being said, it is certainly possible, again treatment is control of the bleeding via ligation, ablation, IR ablation and ultimately, hysterectomy.
Heterotopic Pregnancy: Defined as the coexistence of an intrauterine and extrauterine gestations. Overall incidence is quite varied, original estimates were 1:10,000-50,000 prior to introduction of assisted reproductive therapy. Current incidence has increased to 1:900-7,000 in the setting of varied use of assisted reproductive therapy (1:900 in the case of ovulation induction.) That info mostly for your overall knowledge, as assisted reproductive therapy is not really on the table in Neno. Heterotopic pregnancies (yes, a Zebra) should be thought of in patients with abnormal pain/bleeding and positive pregnancy tests plus 1) assisted reproduction therapy, 2) persistent elevation/rising BHCG levels after a induced/spont abortion, 3) size greater than dates in pregnancy, 4) more than one corpus luteum visualized on ultrasound, 4) clinical presentation concerning for ectopic pregnancy in the setting of an intrauterine pregnancy. Overall treatment and outcomes for heterotopic pregnancies are varied depending on the setting of diagnosis. However, in the setting of hemodynamic instability, laparotomy is the standard of care with goal to achieve hemodynamic stability - most often performed by removal of the ectopic pregnancy with varied survival rates of the intrauterine pregnancy.
Hemorrhagic Ovarian Cyst: Something we are a little more familiar with, so I will limits this discussion a bit more. Again, this is actually more rare in pregnancy than in non-pregnant women. Interestingly, more and more ruptured ovarian cysts are managed conservatively with only about 20% of patients with ruptured ovarian cysts requiring intervention due to excessive blood loss (often predicted by depth of fluid pocket on US or CT as well as decreased diastolic BP.) General DDX for atraumatic hemoperitoneum as well: blood dyscrasia, tumor-associated hemorrhage, vascular lesions/malformations (visceral artery aneurysms and pseudoaneurysms) …..so really we were looking for anything!
Back to our patient: We were lucky/brave enough to join the crew in the operating theater to be able to report the following:
OR COURSE: A mini-laparotomy was performed infraumbilically and frank blood was noted immediately upon entering the peritoneum. ~1500mL of frank blood were suctioned out of the peritoneum. Upon initial inspection of the abdomen, the patient was noted to have an abnormal, fungating growth on the fundus of her uterus which was noted to be oozing fresh blood. The mass was noted to involve the fundus and thought to extend into the right fallopian tube with complete disruption of the serosa. Inspection of the ovaries and adnexa were reportedly normal.
Given the location and extensive involvement of the entire uterine wall and a portion of the right fallopian tube, the decision was made to proceed with a hysterectomy (which of note, took ~4-5hrs as it is not a common procedure done at NDH). Ovaries left in situ. Haemostasis achieved, though while intraop, Hgb 3.5 resulted, thus she was transfused 2 units PRBC intraoperatively. (PRBC were used and no autologous transfusion performed...not sure if they are able to autotransfuse in Neno or not.) Uterus was sent to Blantyre for pathological review, but unfortunately those results are not yet available for our review.
Thankfully, the patient tolerated the procedure well. The remainder of her course is as follows. POD0: Transfused her 3rd unit of PRBC. POD1: Pain improving, sips of water tolerating, off catheter, stop IVF. Complete LA therapy for malaria. POD2: Tolerating porridge and voiding well, repeat FBC ordered. Completed 4 days of periop ceftriaxone. POD3: Pt was discharged and walked out of the hospital with a wave!
To date, we are not aware of the final pathology report. My suspicion after reviewing the differential at length, is that she had a placenta percreta. Hopefully, in the future we will be able to make addendum this case with the final diagnosis.
Sources: Fan, Y et al. Spontaneous rupture of utero-ovarian vessels in pregnancy. Acta Obstet Ginecol Port 2013;7(3):215-218 Govindarajan, MJ et al. Heterotopic pregnancy in natural conception. BMC Womens Health. 2014; 14: 128. Gupta, N et al. Placenta Percreta at 17 weeks with consecutive hysterectomy: A Case Report and Review of the Literature. J Hum Reprod Sci. 2008 Jan-Jun; 1(1): 37–38. Kim, JH et al. Successful Conservative Management of Ruptured Ovarian Cysts with Hemoperitoneum in Healthy Women. Pateman, K et al. Natural history of ovarian endometrioma in pregnancy. PLoS One. 2014; 9(3): e91171. Tikkanen, M et al. Placental previa percreta left in situ. Case Rep Obstet Gynecol. 2012; 2012: 734834.
Ultrasound Findings:
Image 1: Suprapubic, longitudinal orientation demonstrating a viable ~8 week intrauterine pregnancy as well as a large amount of free fluid in the abdomen. Free fluid in this image seen surrounding the uterus superiorly and extending posteriorly into pouch of Douglas.
Image 2: RLQ view, longitudinal orientation. This image was taken just to the right of image #1. Again, large amount of free fluid demonstrated, this image (poorly captured by photographer Draper) demonstrated pronounced layering of the fluid, a characteristic appearance of blood leading to the increasing concern for hemoperitoneum.
Image 3: RUQ, hepatorenal recess. Again, free fluid visualized in Morrison’s pouch/hepatorenal recess.
Image 4: LUQ, splenorenal recess. Free fluid seen surrounding the inferior tip of the spleen. A pan positive FAST exam.
Discussion:
Overall, 24yo G3P2 HIV positive female with history of 1 prior c-section presenting with 1 day of suprapubic abdominal pain, progressing to an acute abdomen with distinct rebound and severe tenderness throughout her abdomen. Initial evaluation was highly concerning for ectopic pregnancy in the setting of positive urine BHCG v appendicitis given fevers and tachycardia. However, abdominal US revealed a viable 8 week intrauterine pregnancy as well as a large amount of intraabdominal free fluid, highly concerning for blood. Pt was also noted to be febrile with MRDT positive for malaria. Thankfully, all the key players in the hospital were called to bedside after our initial exam was so concerning for an acute abdomen and marked intra abdominal fluid.
This is where the power of the bedside sono really became a key player. Neno has a functional operating theater, however, no one seemed too terribly thrilled to expeditiously take this stoic young woman to the OR on a simple clinical diagnosis of acute abdomen. Luckily for her, when multiple Clinical Officers and MD’s were able to see the images of the free fluid, the message became all the more obvious and no one could argue against an expeditious ex-lap.
After many hands confirmed the acute abdomen and many eyes saw the free fluid, she was rather expeditiously taken to the Operating Theater. We quickly researched possible causes of hemoperitoneum in the setting of pregnancy so we could be prepared to help in the hunt for the source of bleeding. So what is the differential for hemoperitoneum in pregnancy? Get ready for a list of zebras!
DDx for Hemoperitoneum in Pregnancy:
Placenta Accreta/Increta/Percreta: A range of pathologies in which there is abnormal invasion of the placenta into the myometrium. This is most commonly found in women with a history of cesarean, as the scar site is commonly the site of abnormal invasion. These related pathologies have different terminology to define the extent of invasion of the placenta into the uterine wall. Placenta accreta is defined as superficial invasion, placenta increta as middle layer invasion and placenta percreta as deep invasion. Placenta percreta is the most severe manifestation with an incidence of ~1:5,000-7,000 pregnancies. (Overall incidence of all forms of placenta accreta has increased significantly from ~1: 30,000 in 1950-60’s to 1:2500 in 2000’s. This is thought to be due to the parallel increase in the number of cesarean deliveries.) All of these pathologies carry a high morbidity given increased risk of hemorrhage, mostly noted during and immediately following delivery. However, I was able to find multiple case reports of placenta percreta in first trimester, most often diagnosed along with complete uterine rupture. Other risks associated with all forms of abnormal placentation include DIC, fetal demise and maternal death. Treatment worldwide is the same, hysterectomy. In the US, there are case reports trialing conservative management when possible (D&C, chemotherapy, attempted IR ablation) though none was found to be superior to hysterectomy, in fact, mortality rates were high in non-hysterectomy treatment.
Endometriosis/Endometrioma: Endometriomas are collections of endometrial tissue found outside the uterus, most commonly in the ovary. These are most often found on ultrasound in the setting of abnormal pelvic pain and bleeding. They can result in hemoperitoneum in the setting of rupture. Interestingly, however, when followed over the course of pregnancy, most endometriomas are found to shrink in size and many even regress in the setting of hormonal changes of pregnancy. pregnancy due to hormonal changes. Overall prevalence in pregnancy is 0.2-0.3%. However, despite their relatively rarity they account for approximately a quarter of all surgical interventions for ovarian cysts detected during pregnancy. Laparoscopy is the standard of care for surgical removal, though many studies report success in serial monitoring if endometriomas are incidental findings on routine ultrasound surveillance. Interestingly, when Jay and I asked about endometriosis in Malawi, none of the providers we spoke with could think of a patient they had diagnosed/or even seen with endometriosis.
Uterine/Ovarian Vessel Rupture: Again, another rarely occurring pathology. In fact, per one article, only 17 cases of utero-ovarian vessel rupture in pregnancy were noted on Medline search from 1987-2013. That being said, it is certainly possible, again treatment is control of the bleeding via ligation, ablation, IR ablation and ultimately, hysterectomy.
Heterotopic Pregnancy: Defined as the coexistence of an intrauterine and extrauterine gestations. Overall incidence is quite varied, original estimates were 1:10,000-50,000 prior to introduction of assisted reproductive therapy. Current incidence has increased to 1:900-7,000 in the setting of varied use of assisted reproductive therapy (1:900 in the case of ovulation induction.) That info mostly for your overall knowledge, as assisted reproductive therapy is not really on the table in Neno. Heterotopic pregnancies (yes, a Zebra) should be thought of in patients with abnormal pain/bleeding and positive pregnancy tests plus 1) assisted reproduction therapy, 2) persistent elevation/rising BHCG levels after a induced/spont abortion, 3) size greater than dates in pregnancy, 4) more than one corpus luteum visualized on ultrasound, 4) clinical presentation concerning for ectopic pregnancy in the setting of an intrauterine pregnancy. Overall treatment and outcomes for heterotopic pregnancies are varied depending on the setting of diagnosis. However, in the setting of hemodynamic instability, laparotomy is the standard of care with goal to achieve hemodynamic stability - most often performed by removal of the ectopic pregnancy with varied survival rates of the intrauterine pregnancy.
Hemorrhagic Ovarian Cyst: Something we are a little more familiar with, so I will limits this discussion a bit more. Again, this is actually more rare in pregnancy than in non-pregnant women. Interestingly, more and more ruptured ovarian cysts are managed conservatively with only about 20% of patients with ruptured ovarian cysts requiring intervention due to excessive blood loss (often predicted by depth of fluid pocket on US or CT as well as decreased diastolic BP.)
General DDX for atraumatic hemoperitoneum as well: blood dyscrasia, tumor-associated
hemorrhage, vascular lesions/malformations (visceral artery aneurysms and pseudoaneurysms)
…..so really we were looking for anything!
Back to our patient:
We were lucky/brave enough to join the crew in the operating theater to be able to report the following:
OR COURSE: A mini-laparotomy was performed infraumbilically and frank blood was noted immediately upon entering the peritoneum. ~1500mL of frank blood were suctioned out of the peritoneum. Upon initial inspection of the abdomen, the patient was noted to have an abnormal, fungating growth on the fundus of her uterus which was noted to be oozing fresh blood. The mass was noted to involve the fundus and thought to extend into the right fallopian tube with complete disruption of the serosa. Inspection of the ovaries and adnexa were reportedly normal.
Given the location and extensive involvement of the entire uterine wall and a portion of the right fallopian tube, the decision was made to proceed with a hysterectomy (which of note, took ~4-5hrs as it is not a common procedure done at NDH). Ovaries left in situ. Haemostasis achieved, though while intraop, Hgb 3.5 resulted, thus she was transfused 2 units PRBC intraoperatively. (PRBC were used and no autologous transfusion performed...not sure if they are able to autotransfuse in Neno or not.) Uterus was sent to Blantyre for pathological review, but unfortunately those results are not yet available for our review.
Thankfully, the patient tolerated the procedure well. The remainder of her course is as follows.
POD0: Transfused her 3rd unit of PRBC.
POD1: Pain improving, sips of water tolerating, off catheter, stop IVF. Complete LA therapy for malaria.
POD2: Tolerating porridge and voiding well, repeat FBC ordered. Completed 4 days of periop ceftriaxone.
POD3: Pt was discharged and walked out of the hospital with a wave!
To date, we are not aware of the final pathology report. My suspicion after reviewing the differential at length, is that she had a placenta percreta. Hopefully, in the future we will be able to make addendum this case with the final diagnosis.
Sources:
Fan, Y et al. Spontaneous rupture of utero-ovarian vessels in pregnancy. Acta Obstet Ginecol Port 2013;7(3):215-218
Govindarajan, MJ et al. Heterotopic pregnancy in natural conception. BMC Womens Health. 2014; 14: 128.
Gupta, N et al. Placenta Percreta at 17 weeks with consecutive hysterectomy: A Case Report and Review of the Literature. J Hum Reprod Sci. 2008 Jan-Jun; 1(1): 37–38.
Kim, JH et al. Successful Conservative Management of Ruptured Ovarian Cysts with Hemoperitoneum in Healthy Women.
Pateman, K et al. Natural history of ovarian endometrioma in pregnancy. PLoS One. 2014; 9(3): e91171.
Tikkanen, M et al. Placental previa percreta left in situ. Case Rep Obstet Gynecol. 2012; 2012: 734834.